Taking a stand together

Government, clinical societies, quality organizations and patient safety groups have taken note of the concerning prevalence of retained surgical items (RSI) and agree there’s more to be done. They’re addressing RSI in various ways including educational efforts, incident reporting, payment structures and protocol recommendations that include adjunctive technology such as the SurgiCount System.

What experts are saying

Association of periOperative Registered Nurses (AORN)

“A multidisciplinary team may evaluate adjunct technologies for use as a supplement to manual counting.”18AORN 2016 Guidelines Recommendation VII

“A systems approach should be used for prevention of RSIs. Healthcare organizations should value learning and respond to errors with a focus on process improvement rather than individual blame.”18AORN 2016 Guidelines Recommendation X

ECRI Institute

“This event [unintended retention of foreign objects] is reflective of system problems and rarely the result of a single individual’s error. Faulty, incomplete, or ineffective systems cause humans to err.” 9ECRI Research Response on Adjunctive Technologies

“The 10 patient safety concerns on this list are very real. They are causing harm—often serious harm—to real people. Fortunately, for all of the patient safety concerns on this year’s list, more can be done.”9William M. Marella, MBA, MMIExecutive Director, PSO Operations and AnalyticsECRI Institute’s Patient Safety, Risk and Quality Group

The Leapfrog Group

“Despite the powerful stories of improving and high-performing hospitals, improvement across the board remains elusive…Hospitals are performing worse on critical measures like foreign objects left in after surgery.”24The Leapfrog GroupFall 2015 Hospital Safety Score Report

RSIs are considered an outcomes measure – a measure of harm experienced by patients – and are weighted at 4.2%.25The Leapfrog GroupSpring 2016 Scoring Methodology

The Joint Commission

Pennsylvania Patient Safety Authority

“Authority reports suggest that RSI prevention remains a challenge and that continued diligence in RSI prevention efforts is essential.”21Pennsylvania Patient Safety AuthoritySafety Advisory

“Because counting alone may be insufficient, the Authority presented multipronged risk reduction strategies, including improved perioperative processes, perioperative team communication, and the use of assistive technology.”21

World Health Organization

“Manual counting methods are not fool-proof, as they are subject to human error. Newer techniques, which include automated counting and tracking of sponges, appear to increase the accuracy of counting and the detection of inadvertently retained sponges.”27World Health OrganizationGuidelines for Safe Surgery

“Surgeons and nurses are the primary defenders against retention, and only behavior change to actually use these safe practices will prevent patient harm.”23Verna C. Gibbs, M.D., Director, No Thing Left Behind

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